Philippa Cheetham, MD: Dr. Martin, when we’re talking to patients with advanced disease, particularly where they have extensive disease beyond the chest with metastatic disease, how difficult is it to have these conversations with patients where you can’t talk about cure?

Sara F. Martin, MD: I think it varies from patient to patient on how difficult it is. It’s always hard for someone to come to terms with the fact that they’re not going to be cured. No one wants to hear “cancer” and then hear that they can’t be cured from cancer. But my focus, and the focus of all palliative care specialists, is really on the person. “What’s important to you?” “What are your values that we need to know about and try to honor?” As long as we can find out as much about the person and their family as possible, and what’s important to them, we can really work with the radiation oncologist, the medical oncologist, and all of the physicians to ensure that we have a treatment plan that maximizes what’s important to them.

Philippa Cheetham, MD: Do you see this now as more of a chronic disease? Lung cancer typically was killing many patients that were diagnosed. Now, survival is improving and the time from progression seems to be getting longer and longer. Do you now see it as more of a chronic disease, where we’ve gotten better at treating patients and not just treating the disease—treating the side effects of both the disease and treatment?

Leora Horn, MD, MSc: Absolutely. When I meet patients for the first time who have stage IV disease, we talk about how we’re going to look at this as a chronic illness with long-term survival. We’re not at decades, and I’m hoping we’ll get there, but we’re definitely at years. And similar to how we think of diabetes or hypertension as a chronic illness, I try to help my patients think about their lung cancer that way as well.

Philippa Cheetham, MD: This is obviously a disease that is frequently diagnosed in patients who don’t always have the best health to start with, particularly if they’ve been long-term heavy smokers. Do you think that has a big impact on how we can treat patients moving forward? If they’ve had another cancer that may have affected their pulmonary status, is that an obstacle? If patients are living longer but they’ve still got all of these other chronic medical issues, how much does the actual smoking history play into the treatments that you could offer and how well patients do? Does that impact survival, if they have all these other comorbidities that ultimately may affect life expectancy?

Leora Horn, MD, MSc: It definitely plays a role. It can play a role in their survival, and it can also play a role in their therapy. So, for example, a patient who has diabetes and has bad numbness, tingling, and neuropathy from their diabetes—he or she may not be able to get some of the chemotherapy drugs that we would like to offer. We know for patients with autoimmune diseases like rheumatoid arthritis and lupus, those patients may not safely be able to get immunotherapy. So, it goes beyond smoking. Any of the comorbid illnesses that we see lung cancer patients present with really can have an impact on us deciding what the best therapeutic strategy for that patient is.

Philippa Cheetham, MD: We know that for patients who are on these systemic treatments, we often have to think about whether drugs are metabolized through the kidneys or the liver and the effects on other organs. How much are these issues concerns for immunotherapy treatments?

Leora Horn, MD, MSc: We know the immunotherapy drugs are not safe to give in a patient who’s had an organ transplant. There was actually data that has been published showing that there’s a high risk of patients rejecting their transplant as a result of those drugs.

For patients with baseline kidney dysfunction, we also know that these drugs can cause liver failure and kidney failure. They really can cause problems in any organ in the body that is subject to an immune reaction. And so, we have to be very good about monitoring patients and alerting them to recognize the symptoms. So, if you suddenly become so short of breath that you can’t get from the chair to the bathroom, you need to come in and be seen. If you suddenly start having 5 or 6 bowel movements a day, you need to come in and be seen. Don’t just wait until your next doctor’s appointment. Call us. We’re open 7 days a week. Our infusion room is open on the weekends. There is always someone on call, 24 hours a day, 7 days a week. It’s really about encouraging patients to be active and call in because we’re not going to call them at home every day and say, “Hey, how are you feeling today?”